In the fall of 2005, the International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations (CoSTR) as well as the American Heart Association’s Guidelines for Emergency Cardiovascular Care (ECC) were published in Circulation. The guidelines were prepared by the American Heart Association Pediatric Subcommittee and American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee based on an extensive review of the existing literature on neonatal resuscitation. The guidelines were used to develop and revise the Textbook of Neonatal Resuscitation, 5th edition, and accompanying Neonatal Resuscitation Program (NRP) education materials. Based on their findings, various changes have been made to the NRP, including new recommendations for the use of supplemental oxygen and endotracheal epinephrine. These changes have the potential for a profound impact on medical practice around the world.Newborns who do not require resuscitation generally can be identified by a rapid assessment of the following four characteristics: Of note, a fifth question, “Is the baby pink?” no longer appears as part of the rapid assessment immediately after birth.The sequential approach to a newborn in the delivery room remains the same (FigureF1). NRP providers should continue to adhere to the ABCs of resuscitation: airway before breathing before circulation. The four categories of action in sequence are: Temperature control continues to be an important focus of resuscitation research. Both hypothermia and hyperthermia may have detrimental effects. Hypothermia has a clear association with increased mortality, especially among low-birthweight infants. Hyperthermia is associated with perinatal respiratory depression, neonatal seizures, and cerebral palsy. Hyperthermia after ischemia in experimental animals is associated with worsening of cerebral injury. Efforts in the delivery room should focus on maintaining normothermic temperatures. Use of polyethylene bags in the delivery room is recommended to help maintain body temperature during resuscitation of very low-birthweight (VLBW) infants.A randomized, controlled study to assess the effectiveness of intrapartum oropharyngeal and nasopharyngeal suctioning for babies born through meconium-stained amniotic fluid found that the common, widely accepted procedure of suctioning did not reduce the incidence of meconium aspiration sydrome. Based on these findings, the new guidelines no longer recommend that all meconium-stained babies routinely receive intrapartum suctioning (ie, before delivery of shoulders). Other recommendations about neonatal suctioning after delivery remain unchanged. The vigor of the infant, rather than the consistency of the meconium-stained fluid, determines whether endotracheal suctioning is necessary.Various changes have been instituted regarding the use of supplemental oxygen in the delivery room. For term infants, 100% supplemental oxygen is recommended when an infant has cyanosis or when positive-pressure ventilation is required during resuscitation. Whether room air (or something between room air and 100% Fio2) may be as successful for resuscitation remains controversial and continues to be investigated. However, if resuscitation is started with less than 100% oxygen, supplemental oxygen up to 100% should be administered if there is no appreciable improvement within 90 seconds following birth. If supplemental oxygen is unavailable, room air should be used to deliver positive-pressure ventilation.Both ILCOR and the NRP now recommend the use of an oxygen blender and pulse oximetry in the delivery room for preterm infants, especially those born at less than 32 weeks’ gestation. Initial resuscitation should begin with an oxygen concentration between room air and 100% oxygen (although no specific starting value is recommended), and the Fio2 should be increased only if the infant’s heart rate remains less than 100 beats/min or the infant exhibits cyanosis. The infant’s pulse oximetry reading should increase gradually toward 90% with successful resuscitation. The Fio2 should be weaned for an oxygen saturation greater than 95%. If no oxygen blender is available, 100% oxygen should be used. There is no convincing evidence that a brief period of 100% oxygen during resuscitation will be detrimental to the preterm infant. However, NRP suggests potentially transferring the mother to another facility with oxygen blenders and pulse oximeters in the delivery room prior to delivery, if possible. The potential economic impact of this major change in clinical practice may be substantial.Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised infant. Indications for positive-pressure ventilation include apnea/gasping, a heart rate of less than 100 beats/min, and persistent central cyanosis despite 100% free flow oxygen.Two types of resuscitation bags, self-inflating and flow-inflating, may be used to ventilate a baby. A third type of resuscitation device, the T-piece resuscitator, can be used to deliver positive-pressure ventilation and can deliver up to 100% oxygen. This mechanical device depends on a compressed gas source and must have a tight face-mask seal to inflate the lungs. The operator sets maximum circuit pressure and positive end expiratory pressure (PEEP). A positive-pressure breath is provided by alternately occluding and releasing the hole in the PEEP cap. Peak inspiratory pressure must be adjusted during resuscitation to achieve physiologic improvement (heart rate and color), audible breath sounds, and perceptible chest movements.It is now recommended that bag-and-mask ventilation include at least two persons, with one person performing ventilation, while the other evaluates the response. Heart rate is assessed initially, and if not improving, chest movement and breath sounds are verified. Increasing heart rate is the primary sign of effective ventilation during resuscitation. Other signs are improving color, spontaneous breathing, and improving muscle tone.The laryngeal mask airway has been shown to be effective for assisting ventilation of term and near-term newborns. Data are limited, however, for small preterm infants, and there is no direct comparison of laryngeal mask with bag-and-mask ventilation for initial resuscitation. When bag-and-mask ventilation is unsuccessful and endotracheal intubation is not possible, the laryngeal mask may be an effective alternative.The combination of an increasing heart rate and CO2 detection now is considered the primary method for confirming endotracheal tube placement and adequate ventilation. When the heart rate does not increase promptly after endotracheal intubation, use of a CO2 detector can help differentiate between tube malposition and the need for greater ventilatory support. Two types of CO2 detectors are used commonly in the delivery room to validate proper placement of the endotracheal tube. The first is a colorimetric device, the most commonly used method to detect CO2. This device connects to the endotracheal tube and changes color in the presence of CO2. The other method, capnography, relies on placement of a special electrode at the endotracheal tube connector. The capnograph displays a specific CO2 concentration and should indicate more than 2% to 3% saturation of CO2 if the tube is in the trachea. The CO2 detector should be connected as soon as the endotracheal tube has been inserted, noting the presence or absence of CO2 during exhalation. If CO2 is not detected after several positive-pressure breaths, the clinician should consider removing the tube, resuming bag-and-mask ventilation, and repeating the intubation process. It is important to note that a CO2 detector may not change color if a baby’s cardiac output is very low or absent, such as in the event of cardiac arrest.Significant changes are reflected in the dosing guidelines for endotracheal epinephrine administration. Numerous animal models and studies in adults have suggested that larger doses of endotracheal epinephrine are needed to achieve physiologic effects comparable to intravenous (IV) epinephrine doses. IV administration is preferred because endotracheal dosing is less predictable and efficacious. However, while IV access is being obtained, administration of a higher dose of endotracheal epinephrine (0.03 to 0.1 mg/kg) may be considered. The safety and efficacy of these higher doses, however, have not been studied sufficiently in neonatal resuscitation. Until such information is available, IV administration is the preferred route of delivery. A 3-mL syringe should be used for endotracheal administration and a 1-mL syringe for IV dosing. Recommended doses are: Naloxone administration is not recommended during the primary steps of resuscitation. This agent should be used only in infants who experience continued respiratory depression after positive-pressure ventilation has restored a normal heart rate and color and when there is a history of maternal narcotics within 4 hours of delivery. The preferred routes are either IV or intramuscular. Given the lack of clinical data in newborns, endotracheal administration of naloxone is not recommended.Infants who require resuscitation are at risk for deterioration after their vital signs have returned to normal. Once adequate ventilation and circulation have been established, the infant should be maintained in or transferred to an environment in which close monitoring and anticipatory care can be provided.Infants who require significant resuscitation should be monitored and treated to maintain glucose in the normal range.Hypothermia may reduce the extent of brain injury following hypoxia-ischemia. There are insufficient data to recommend routine use of modest selective or systemic hypothermia after resuscitation of infants in whom asphyxia is suspected. Further clinical trials are needed to determine which infants benefit and which method of cooling is most effective as well as timing and duration of therapy. Avoidance of hyperthermia is particularly important in babies who may have had a hypoxic-ischemic event.A consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents is an important goal. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely. The following guidelines must be interpreted according to current regional outcomes: Under any circumstances, discontinuation of resuscitation efforts may be appropriate after 10 minutes of absent heart rate following complete and adequate resuscitation efforts. Consistent, sensitive, and compassionate care for dying infants and their families requires advance preparation, coordination, training, practice, and skillful communication with cultural appropriateness.The NRP always has incorporated performance checklists and a megacode to assess behavioral and psychomotor skills as well as cognitive knowledge. Many educators have argued that this form of assessment is too subjective. In response to such arguments, the new edition of NRP incorporates a new validated and scored megacode checklist assessment. This checklist was developed using feedback from more than 800 NRP instructors and video footage from actual megacodes. A student must score greater than 85% to pass the megacode, which is a required element of course completion. The new edition also provides educational suggestions based in well-founded educational theory to improve instruction. For example, instructors are encouraged to model expert behavior prior to initiating the megacode. Bandura’s Social Behavioral Learning Theory, which deals with the acquisition of behaviors, contends that people acquire behaviors through the observation of others, and they then imitate what they have observed. As crises in the delivery room are unpredictable, so will be the students’ exposure to such emergencies. Modeling expert behavior in a training situation allows trainees to incorporate more than technical and cognitive skills into their internal database of NRP knowledge. The new edition also provides detailed suggestions aimed at enhancing the learning environment for delivery of NRP instruction.Familiarization with the changes in the new NRP guidelines should improve instructor preparedness. Timely implementation of educational plans to incorporate the guidelines into NRP training is imperative.